5 Education and Competency Training

One of the most important aspects of any bariatric program is education, training, and competence. The first step is to bring facility-wide awareness of the bias and discrimination that most bariatric patients experience. Sensitivity training is critical to ensure that every aspect of a patient’s journey is healthy and respectful (Gallagher, 2011). There are many other aspects of caring for bariatric patients that caregivers will need as well, such as information on technology and safe patient handling and mobility (SPHM) techniques, along with education regarding the many co-morbid conditions that bariatric patients face. Lastly, education would not be complete if we did not address the learning needs of the patients and their families or caregivers. This chapter will provide information on what to include in the education, training, and competence.

5.1. Sensitivity

In a society that generally relates beauty, intelligence, and success with thinness, being overweight has emotional, financial, and social consequences. It is not uncommon for overweight individuals to experience psychological stress, reduced income, and overall discrimination. One of the greatest sources of harm for the bariatric patient is the emotional harm that occurs as a consequence of bias and discrimination. Empathy training provides caregivers the opportunity to better understand the lived experience of being a person of size.

Caregivers best serve bariatric patients when they recognize the real and painful bias obese patients experience every day. Studies as far back as 1982 found that subjects identified the obese individual as lazy, dirty, and ugly (Klein, Najman, Kohrman, Munro, 1982). The concept of “otherness” is often assigned to the obese person individually and obesity collectively (Gallagher, 2015). Otherness allows society to blame the patient for their condition of obesity, rather than seek ways to improve care through reasonable accommodation, which is common practice when caring for others who suffer from a disability.

Studies show that health care providers view obese persons as unintelligent, noncompliant, indulgent, hostile, dishonest, unsuccessful, inactive, and weak-willed (Vacek, 2007). These studies also indicate that physicians preferred not to treat obese patients and did not expect success when they were responsible for the management of a bariatric patient’s care. Nurses also have many biases, and nearly half of those surveyed stated they were uncomfortable caring for obese patients. Nurses indicated that they believe obesity can be prevented by selfcontrol and obese patients are over-indulgent, non-compliant, and lazy. These biases leave the bariatric patient filled with fear and isolation. Obese people often delay going to see their primary provider because they are afraid of being embarrassed or humiliated.

A brief glimpse into a bariatric patient’s hospital or clinic visit starts out with a public weighing and possibly even a loud conversation about the weight capacity of the scale. Next, the individual may be directed to furniture that is too small, asked to climb onto an exam table that is too narrow, and given an ill-fitting gown. Obese individuals face constant lecturing regarding weight loss, and they often hold the perception that caregivers dislike them, and in fact, as the previously mentioned studies show, they are often correct.

An all-new view of the bariatric patient based on respect, care, and compassion is needed. Sensitivity starts with empathy and understanding the bariatric patient first as a human being. The relationship established with the patient starts with a friendly approach, being fully present, and willing to explore mutually-responsive decision making. Caregivers who focus on the patient, not their obesity, are more likely to see positive results. Some additional things to challenge the bias include weighing the patient in a private area and not stating the weight aloud in public, and also avoiding loud requests for help and overhead pages, as these can be extremely embarrassing for the patient. Ensure that bariatric supplies (i.e., gown and blood pressure cuff) and furniture are available; this will send the message that you are ready and able to take care of their needs. Caregivers must also become aware of their body language, facial expressions, and tone of voice. They should challenge others’ language that is hurtful, even when it is done away from the patient.

Another aspect of sensitive care is focusing on the patient’s chief complaint, especially in the primary or clinic care setting. Health care providers in the postacute care environment often assume that weight loss is the top priority for all bariatric patients and focus on this, but it is important to take the time to fully understand what the patient feels is important. A common issue faced by most bariatric patients is that regardless of the presenting problem, the solution offered by health care providers is weight loss. Patients coming into the clinic for foot pain are told if they lose weight, the condition will improve. While in reality, the weight loss would help the foot pain; the patient leaves the appointment thinking that their weight was all that was addressed. Allowing the bariatric patient to identify what is important to them in their health care plan is part of sensitive care. Some bariatric patients may be working toward increasing their independence and mobility, including getting in/out of a chair independently, getting on/off the commode independently, being able to wash/dress with minimal help, to walk short distances, or to go to public places with minimal assistance. Other bariatric patients may be independent and able to attend to all the activities of daily living but are working on other medical challenges, such as diabetes or cardiac issues. Sensitive care begins with learning what is important to the patient, finding out their definition of health, and assisting them towards their goals to attain a healthy lifestyle.

An early step in sensitivity training is to define bias and stigma. Bias is described as the negative attitudes that influence interactions. Weight bias leads to stereotypes, rejection, prejudice, and discrimination (retrieved from http://www.obesity.org/resources-for/obesity-bias-and-stigmatization.htm). A stigma creates an atmosphere of blame and intolerance, reduces quality of life, and results in serious psychological, social, and physical health consequences (Puhl & Heuer, 2010). Awareness of both personal biases and those present in the occupational setting is the next step in creating a respectful environment for the bariatric patient. What are your first thoughts when you find out you will be caring for a bariatric patient? What language do you use when working with a bariatric patient? Does your work area have access to basic SPHM technology and supplies that accommodate a bariatric patient? How is this technology identified? Understanding bias both from a caregiver and a patient perspective begin the journey to more mindful patient care.

In summary, the biases and stigma that bariatric patients experience are real and often have a detrimental effect on their health. Bariatric patients have a right to the same quality of care, provided in a safe and dignified manner, as any other patient with a chronic disease. Many factors contribute to the causes of obesity, and it is time to move beyond the focus of who is to blame and work to treat the whole patient. Sensitivity training will make available the necessary tools health care providers and caregivers need to provide respectful, compassionate care for the bariatric patient.

5.2. Staff Education and Training

All bariatric patient handling and mobility tasks require specialized knowledge and training to ensure safe and effective care. Various modalities and levels of training are needed, and the objectives will guide the method, format, and duration of the training. This training may include just-in-time training, classroom, electronic computer modules, hands-on training, peer-to-peer coaching, or a blended combination.

If the objective is to promote awareness, classroom sessions providing a comprehensive overview of the complexity of care of the bariatric patient may be the best method to achieve the goal. Awareness training sessions should include a foundation that defines the obesity epidemic and sensitivity training regarding the bias and negative judgments often directed towards bariatric patients. This training is required for all staff, including all direct care providers, physicians, housekeepers, managers, and new employees. A more advanced training should include information on the space and technology needs for safe bariatric care, an understanding of the co-morbidities that occur in the bariatric patient, and assessment and decision making tools, such as algorithms. This training is required for all direct care providers and Unit Peer Leaders (UPLs), with the UPL training being more advanced and a longer duration. Enclosure 5-1 is an example of a Power Point Presentation that includes an overview of bariatrics and detailed space and design criteria. This presentation may be used in PDF format but not modified. Enclosure 5-2 is another example of a Power Point presentation that includes an overview of bariatrics, bariatric technology and equipment, comorbid conditions, and sensitivity/dignity/respect. This presentation can be used and/or modified to meet your needs. Pictures have been removed due to copyright issues, but may be added for increased visualization of content. If the objective is to develop skills, hands-on technology training is the best method. This may occur as an annual competency training or “just-in-time” if rental equipment is being used. A bariatric simulation manikin may be an effective method for practice with SPHM tasks in a safe setting.

As with all SPHM education, the concepts of adult learning need to be incorporated into the training. Adults learn best when they are able to integrate life experiences into their learning, and a variety of teaching strategies are used Interactive and participatory training is preferred Examples of this include asking the participants to share past experiences with bariatric patients. Sharing stories of what has worked, as well as barriers to safe care, provide an effective learning strategy. Simulation training is also an effective way to demonstrate how to perform patient handling tasks in a safe environment before being faced with the challenges of real-life experiences.

Education, training, and competency evaluations must be provided for all health care workers across the continuum of care who have direct clinical contact with bariatric patients, including, but not limited to, nurses, nursing assistants, health technicians, radiology technicians, and physical and occupational therapists (see Enclosure 5-3 for an example of a Bariatric Training Competency Template). Training needs to be provided annually, if not more frequently, since training may be forgotten if not used regularly and equipment and technology are constantly changing. Annual competencies on technology are particularly important for both the safety of the patient and the staff. It is also essential to educate and involve leadership in the Bariatric SPHM Program so that they understand the challenges faced when caring for the bariatric patient.

Ensuring that the training has been completed by all staff in settings where care is provided 24/7 can be challenging. Management must be involved to make sure all staff are given time to complete the training. The use of peer experts who are trained in bariatric patient care can be an effective means to bring the training to the bedside. Peer leaders are trained to be content experts, as well as technology super-users so that staff has a resource readily available. Managers can support the process by attending the training themselves and also validating the credibility of the peer leaders as experts.

Once the basic knowledge and skills have been developed, it will be important to follow-up with real life reinforcement to ensure the content moves to a level of critical thinking and comprehension. Mock drills or simulation training on the unit are great ways to allow staff to get comfortable with their knowledge and skills. As units receive bariatric patients, refresher training needs to be made available. Techniques that have been individualized for a specific patient based on their mobility and capability to attend to activities of daily living need to be communicated.

Education on the care of bariatric patients should be included in new clinical employee orientation and student orientation and updated with annual training and competency evaluations through a variety of modalities to support staff awareness and proficiency. Records to document completion of competency training should be maintained as appropriate to the facility, which may be facilitated by the unit manager, unit or staff development educator, or the SPHM Coordinator. By incorporating a variety of training strategies, facilities can ensure that bariatric patients will receive compassionate care that is designed to meet the patient handling needs and effectively manage their medical needs. The following table may help determine what training needs to be provided and who should be required to complete it.

Table 5-1: Training Required for Care of Bariatric Patients

5.3. Patient and Family Education

Patient education is a key component for the management of many acute and chronic conditions. For the bariatric patient, even a simple wellness check with a primary care provider can be very stressful and uncomfortable. The patient may encounter bias and judgment, along with lack of appropriately-sized furniture and equipment, which may lead to distrust of the health care system. Many bariatric patients opt to avoid health care until their condition becomes critical. One way to stop the avoidance cycle is to empower bariatric patients by providing them with the knowledge they need to make sound health care decisions. Having easily understood care instructions and other information can put them on the right track for health.

Patients seek information about wellness, illness and disease, health promotion, and health care risks in many ways. The availability of health care information to patients has changed dramatically over the past several decades. Gone are the days when patients take what their doctor says as unquestionable truth. Patients and their family members are active participants in medical decision-making and will use all available resources to make informed decisions. Often patients start with information attained through TV, radio, co-workers, friends, family, and the Internet. Unfortunately, many patients and their families cannot discern between credible and non-credible information. It is the job of the health care provider to ensure that the patient and their family have accurate and easily understood education materials.

Providing education materials in a wide array of formats can further promote the patient’s maximum confidence and cooperation. The educational materials should include definitions of the SPHM and bariatric terminology used, information about the Bariatric SPHM Program, and the available resources and technology they can expect to encounter during their hospital stay. It will be helpful to include rationale for why the technology is needed. Patients and their families will also need information to help them cope with the numerous co-morbidities that are often experienced by this population. A bariatric patient who holds this knowledge will be able to participate in their care, and the result is improved overall outcomes.

Health care education materials should be available in a variety of modalities, such as patient education brochures (see Enclosure 5-4), Web-based interactive tools, or education programs broadcast on patient TVs. Literacy must be considered when developing written patient education tools. Patients with less than basic literacy are not likely to choose written materials, such as books, magazines, or brochures. These patients often look for their facts on television or radio or from friends and family members (Kutner, Greenberg, Jin, & Paulsen, 2006). It is important to allow the patient time during the appointment for reviewing educational materials and time afterward to ask questions of the provider. Ongoing patient teaching may be necessary and offered at every encounter.

How does a provider know which education modality will best meet the patient’s needs? The simple answer is to have many options available and ask the patient which one they prefer. Ask the patient how they learn best and match that style. In this electronic age, many patients prefer to get their information electronically. When using electronic teaching tools, ensure that the materials are user-friendly, convenient, easily accessible, and available in real time. If the patient prefers written instructions or desires to take notes, have brochures and a pen and paper available. If teaching new skills, provide a demonstration followed by return demonstration of the skill. Give the patient and family time to become comfortable with new SPHM technology or other equipment. If they have questions or problems, encourage them to work through their problems so that they can be self-sufficient in the home setting. Providing adequate instructions and training, engaging the patient, and allowing time to feel confident in self-care are critical in supporting our bariatric patients to wellness.

5.4. Enclosures

5-1 Understanding the Special Needs of the Bariatric Population: Design, Innovation, and Respect

5-2 Sample PowerPoint Presentation: Safe Handling and the Patient of Size

5-3 Competency Template

5-4 Sample Bariatric Patient Education Brochure